Web-Based Delivery of the Caregiving Essentials Course for Informal Caregivers of Older Adults in Ontario: Mixed Methods Evaluation Study
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JMIR AGING Rottenberg & Williams
Original Paper
Web-Based Delivery of the Caregiving Essentials Course for
Informal Caregivers of Older Adults in Ontario: Mixed Methods
Evaluation Study
Shelley Rottenberg, BSc, MA; Allison Williams, BA, MA, PhD
School of Earth, Environment & Society, McMaster University, Hamilton, ON, Canada
Corresponding Author:
Shelley Rottenberg, BSc, MA
School of Earth, Environment & Society
McMaster University
1280 Main Street West
Hamilton, ON, L8S 4L8
Canada
Phone: 1 905 802 5036
Email: rottensm@mcmaster.ca
Abstract
Background: Many informal caregivers of older adults have limited time because of the number of responsibilities that their
caregiving role entails. This population often experiences high levels of burden due to the stressful nature of their work and are
vulnerable to developing negative psychological health outcomes. Easily accessible and flexible knowledge interventions are
needed to alleviate the burden and stress experienced by this group.
Objective: This study aims to evaluate the acceptability of the web-based delivery of the Caregiving Essentials course for
informal caregivers of older adults. Both the strengths and limitations of using a web-based platform to provide information and
resources were explored to see whether the method of delivery enhanced or hindered the overall course experience for participants.
Methods: A mixed methodology of web-based pre- (n=111) and postcourse surveys (n=39) and telephone interviews (n=26)
was used to collect both qualitative and quantitative data from participants. Individual interviews were also conducted with key
stakeholders (n=6), and a focus group was conducted with nursing students (n=5) who were involved in the project.
Results: The web-based delivery of the course provided participants with greater accessibility to the course because it allowed
them to work independently through the modules at their own pace wherever and whenever. The discussion boards were also
identified as a major strength because of the opportunity for social interaction and the sense of community that many felt through
sharing their experiences. Some barriers to participation included age-related factors, issues with navigating aspects of the course,
and concerns about privacy and anonymity. Some key suggestions included more engaging methods of web-based communication
and the reorganization of the module content to reduce the amount of text and streamline information.
Conclusions: The web-based delivery of Caregiving Essentials appeared to enhance the overall course experience by increasing
accessibility and allowing participants to interact with the learning materials and other caregivers. The findings from this evaluation
can be used to create and improve the web-based delivery of both the current and emerging interventions for caregivers.
(JMIR Aging 2021;4(2):e25671) doi: 10.2196/25671
KEYWORDS
informal caregivers; family caregivers; older adults; elder care; web-based intervention; online intervention; online course; health
education; eHealth; evaluation
disability [1]. Family members often take on these roles and act
Introduction as the primary support systems, especially when the care
Background recipient is an older adult [2]. Caregiving responsibilities involve
identifying and addressing needs through direct care provision,
Informal caregivers are those who provide unpaid care to care management, or a combination of both [3]. Traditionally,
someone with at least 1 short- or long-term health condition or this work was done by spouses, daughters, or daughters-in-law,
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given the gendered nature of caregiving work [3]. As of 2012, single-component programs [10]. Psychoeducational
most informal caregivers in Canada were women (53%) [4], interventions that can be personalized allow for more significant
and in 2018, most (61%) were aged between 45 years and 64 effects because of targeted intervention delivery [14].
years, and almost half (47%) were the adult children or
Although traditional face-to-face interventions are more
children-in-law of their care recipients [5].
common, eHealth interventions are growing in popularity. The
There is a growing number of Canadians engaging in unpaid, number of people seeking web-based support is increasing [15],
informal care work [6]. This is largely caused by Canada’s aging as is the number of internet users who are older adults [16].
population, which is an increasing demographic trend. Another Therefore, web-based interventions fit with the contemporary
contributing factor is the shift in the responsibility of care from behavior of many informal caregivers today. In addition, they
institutions to communities and families. In 2018, 7.8 million allow for both individualization and the use of multiple
Canadians reported having provided care to a family member components. The 4 major components of internet-based
or friend with a long-term health condition, disability, or aging interventions are (1) content, (2) multimedia, (3) interactive
need [5]. The number of Canadians who will need to be cared web-based activities, and (4) guidance and supportive feedback
for is expected to double over the next 30 years [7]. Caregivers [17].
identified age-related needs as the single most common problem
Several web-based interventions have been conducted for
for which they required help [6]. Therefore, the percentage of
different types of informal caregivers, demonstrating the
the population engaging in informal care work is likely to
feasibility of using this mode of delivery. In a systematic review,
continue to grow in the coming years.
the results indicated that internet interventions can improve
The informal caregiving of an older adult is often overwhelming various aspects of caregiver well-being [16]. Similarly, in
and stressful because of the diversity of responsibilities and the another systematic review, the impact of web-based
unpredictable nature of the work. It usually calls for a mixture interventions for caregivers was deemed to be clearly positive,
of emotional, physical, psychological, social, and financial with improvements in self-efficacy, anxiety, and depression
support from the caregiver on a regular basis [8]. In addition, observed [18]. Other promising web-based intervention
the role requires a knowledge base and skill set that many family outcomes have been seen, such as a reduction in caregiver
members and friends are unequipped with at the onset of their burden [19], an increase in social support and role awareness
caregiving journey [3,9]. In many cases, family caregivers must [20], and a greater intention to access help from others [12].
learn information and seek out resources along the way, which
In terms of the acceptability of web-based delivery, caregivers
further adds to the burden they experience. Sometimes, people
responded positively to initiatives involving web-based
may be unexpectedly thrown into the role of caregiving when
education and internet support groups [21]. For example, in a
health complications arise suddenly in a friend or family
pilot study on a videoconferencing intervention, 95% of the
member. In some cases, informal caregivers assume the role
family caregiver participants reported that using computers for
because it is seen as a family obligation [10]. Consequently, it
group meetings was either very positive or moderately positive
is crucial that caregivers have access to proper support and
[22]. Moreover, it has been shown that internet-based
resources to help alleviate stress and potential negative health
interventions for informal caregivers are acceptable and just as
outcomes.
effective as the conventional face-to-face interventions [18].
However, the availability and accessibility of formal care
Due to service access limitations, informal caregivers may not
services are not equally distributed across space [1]. Rural and
want or be able to use formal care services and other resources.
remote locations have little to no services to support a family
Therefore, internet interventions can provide education and
member providing care for an older adult. Even for the resources
support to informal caregivers facing participation barriers [22].
that do exist in rural areas, limitations such as distance and
Furthermore, as web-based interventions are generally more
money may prevent caregivers from accessing them. When
cost-effective and accessible to informal caregivers than
informal caregivers are isolated from the health care system and
in-person interventions, they present promising opportunities
trained professionals, they experience more unmet tangible
for scalability [23].
needs and, thus, more burden. This accessibility gap between
urban and rural caregivers can result in differential health status Accessibility and asynchronism, which is the lack of
among the care recipients [11]. Consequently, there is a simultaneous occurrence, were the 2 advantages identified by
significant need for more easily accessible information to be participants regarding the web-based modality of a training
available for informal caregivers of older adults, irrespective program [14]. Participants in that intervention also emphasized
of where they live. the importance of interacting with other caregivers because it
reduced social isolation [14]. In another study on internet-based
Previous Work support, the findings revealed that anonymity, asynchronism,
Many interventions have been implemented over the years to and connectivity were the main advantages of
meet the needs of informal caregivers of older adults. The computer-mediated communication [15]. In terms of connecting
literature shows that interventions that are individually tailored with other caregivers, participants were more engaged and
and have multiple components are the most effective types for experienced more benefits when the intervention type was more
this population [12,13]. Research has indicated that interventions interactive [10]. One systematic review observed that interactive
with multiple components have led to stronger physical and web-based activities paired with the provision of human support
mental health benefits for participants when compared with
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were helpful in enhancing the psychological well-being of and understanding by completing self-check quizzes. The
caregivers [17]. Caregiver Action Plan, a digital guide created to supplement
the course, is linked to certain exercises woven across the
Despite the many positive outcomes of internet-based
modules. It provides participants with an individualized and
interventions and the several strengths of web-based delivery,
practical resource at the end of the course. There are also
there is a lack of randomized controlled trials [23]. The
prompts within each module that are connected to discussion
heterogeneity in intervention design, methodologies, outcomes,
board threads, where participants can engage with each other
and participant characteristics, among others, makes cross
on the web.
comparison unattainable. More rigorous study designs and
stronger methods would allow for more robust conclusions on The aim of this study is to evaluate the acceptability of the
the efficacy of such interventions for informal caregivers of web-based delivery of the Caregiving Essentials course for
older adults [21]. Further research should be conducted to informal caregivers of older adults. To determine whether the
determine which types of web-based interventions work best web-based delivery was well received and its impact on the
for which types of caregivers [24]. usability of the course overall, those involved in the project
were asked to provide feedback after course completion.
Context and Goal of the Study Strengths, limitations, and areas of improvement related to the
The Caregiving Essentials course [25] is a no-cost knowledge web-based functionality were identified by participants to
intervention hosted on Desire2Learn. The self-paced 8-week determine whether the method of delivery enhanced or hindered
course was created by team members from the McMaster Centre different aspects of the user experience.
for Continuing Education, the McMaster Institute for Research
on Aging, and the Thrive Group to meet the needs of informal Methods
caregivers for practical, accessible, and timely information [26].
The web-based course was launched with 2 pilot offerings, one Recruitment
in the fall of 2018 and the other in the winter of 2019. The The inclusion criteria for the Caregiving Essentials course
course aimed to enhance caregivers’ knowledge and confidence specified that participants must be the primary caregiver to an
regarding health care issues pertaining to older adults, improve older adult (65 years or older) who is still living at home.
caregivers’ understanding and access to health and community Recruitment strategies targeted people residing in Hamilton,
care systems, and increase caregivers’ personal health and Sudbury, or Timmins for the fall course offering, and then
well-being. efforts were expanded to anywhere in Ontario for the winter
Caregiving Essentials includes 4 stand-alone modules, each course offering. Participants were recruited using various
with a specific focus, and a resources module that features community partner networks, such as long-term care homes,
carefully selected materials. The module titles are as follows: respite relief services, senior community centers, and academic
(1) You and the Caregiver Role; (2) Your Caregiver Toolbox: institutions. The participants involved in the course evaluation
Health and Medical Fundamentals; (3) Navigating Complex were informal caregivers of older adults who had finished the
Systems and Getting the Support You Need; (4) The Importance majority of the module material by the official course end date.
of Looking After You; and (5) Resources. The curriculum offers Participation in the evaluation was not a compulsory component
users reliable, relevant, and up-to-date information on key topics of the course; therefore, data were only collected from those
related to the caregiving journey. Content was gathered from who were willing to offer their feedback (Table 1). The course
credible sources, such as the McMaster Optimal Aging Portal users who completed all elements of the evaluation (pre- and
[27], and was reviewed by subject matter experts. Following postcourse surveys and a telephone interview) received a Can
each module, participants can assess their level of knowledge $20.00 (US $16.58) Tim Hortons gift card as a token of
appreciation.
Table 1. Caregiver participants’ engagement numbers.
Pilot course offering Recruitment inquiries Course registrants Precourse surveys com- Postcourse surveys Telephone interviews
pleted completed conducted
Total, n 315 140 111 39 26
Fall 2018, n (%) 150 (47.6) 70 (50) 52 (46.8) 20 (51.3) 14 (53.8)
Winter 2019, n (%) 165 (52.4) 70 (50) 59 (53.2) 19 (48.7) 12 (46.2)
Recruitment for the project was done via email communication, members. In addition, 5 nursing students who moderated the
and both electronic and verbal consent were obtained. A total course discussion boards and offered support to participants
of 14 participants from the fall course offering and 12 through email were invited to provide qualitative feedback on
participants from the winter course offering agreed to an web-based delivery via a focus group. Thus, the total sample
interview. In addition, 6 key project stakeholders were recruited size for the qualitative data was 37.
to participate in the evaluation. This subsample comprised 1
project leader, 1 project coordinator, 1 subject matter expert, 1
instructional designer, and 2 project advisory committee
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Data Collection supported the major findings in terms of overlapping identified
A mixed methodology was used to evaluate web-based delivery themes. Therefore, methodological triangulation was conducted
of the course. Participants were asked to complete a web-based by cross analyzing the 3 different forms of data collection. The
precourse survey that contained close-ended questions about survey data, interview data, and focus group data helped to
their experience as a caregiver, their access to and use of ensure the validity of the key findings. The audio-recorded
technology, and demographic information for both themselves interviews and focus group were transcribed and analyzed using
and their care recipient. Participants were then asked to complete thematic coding in NVivo 12 Pro (QSR International). An
a postcourse survey that contained the same questions as the inductive approach was used to identify 35 unique nodes and
precourse survey, with an extra section about their experience subfolders, which eventually led to the formation of overarching
taking the course. Both quantitative surveys were administered themes related to the main objective. These themes include
anonymously on the web through LimeSurvey. Thus, accessibility to and within the course, level of interaction
participants’ confidentiality was maintained, as the answers between peers and with the content, comfortability with and
could not be linked to individual participants. barriers to using technology, and scalability of the project.
Caregivers who finished most of the module content were Respondents were categorized based on their participant group
invited to participate in one-on-one telephone interviews to (caregiver, stakeholder, or nursing student). If the participant
provide more in-depth feedback. A semistructured interview was a caregiver, they were further categorized based on which
guide with open-ended questions was used to ask participants course offering they took (Fall 2018 or Winter 2019). Therefore,
about usability, accessibility, level of interaction, strengths, the identifier F11 refers to a caregiver participant from the fall
weaknesses, and areas of improvement regarding the Caregiving course offering, the identifier W2 refers to a caregiver
Essentials course. A total of 26 participant interviews were participant from the winter course offering, S2 refers to a
conducted. Qualitative feedback was also collected via telephone stakeholder participant, and NS5 refers to a nursing student
interviews with 6 key project stakeholders. This interview guide participant.
focused on the strengths, weaknesses, areas of improvement,
and scalability of the course. In addition, a web-based focus Results
group was conducted with 5 nursing students who played an
Participants
active role in the course. Similarly, they were asked a
combination of questions from both the participant and As noted in Table 2, slightly more than half (21/39, 54%) of
stakeholder interview guides. those who participated in the postcourse survey (n=39) were
aged between 45 years and 64 years, most self-identified as
Data Analysis female (28/39, 72%), many (17/39, 44%) were providing care
The survey data collected from participants before and after the to a parent, about half (21/39, 53%) had been a caregiver for 1
course could not be compared because there was a significant to 3 years, almost half (19/39, 49%) were either employed
difference between the number of people who completed the part-time or full-time when they completed the survey, and
precourse survey and those who completed the postcourse one-third (13/39, 33%) reported providing informal care for
survey (Table 1). However, the postcourse survey responses more than 15 hours per week.
were compared with the qualitative interview feedback and
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Table 2. Participant information from the postcourse survey (n=39).a
Postcourse survey questions and options Participant, n (%)
What is your age? (years)
18-24 3 (8)
25-34 1 (3)
35-44 1 (3)
45-54 7 (18)
55-64 14 (36)
65-74 3 (8)
≥75 4 (10)
What is your sex?
Male 5 (13)
Female 28 (72)
Other 0 (0)
What is your relationship with this person? Your care recipient is...
Your parent 17 (44)
Your spouse 7 (18)
A family member 4 (10)
A friend 0 (0)
Other 5 (13)
Approximately how many hours per week do you provide care to this person?
1-4 6 (15)
5-9 8 (21)
10-14 5 (13)
15-19 2 (5)
≥20 11 (28)
Are you currently employed?
Yes: full-time 15 (38)
Yes: part-time 4 (10)
No 10 (26)
Other, please specify 4 (10)
How long have you been a caregiver? (years)JMIR AGING Rottenberg & Williams
a
Response rate was not 100% for each question.
One project stakeholder expressed their understanding of the
Strengths of Web-Based Delivery importance of web-based delivery for the course:
Most of the caregivers who participated in the evaluation
component of the project stated that they preferred it over an People don’t want to come out or maybe they can’t
in-person intervention. One participant said: get out because of that person that they have at home
and it’s not easy to find some relief ... The online was
If I had to show up at a place, I probably would not just vital. [S2]
have participated as much as being able to do it These positive interview comments correlate with the high
online. [W2] number of caregiver respondents who agreed (30/35, 86%) or
Similarly, another interviewee said: somewhat agreed (4/35, 11%) to survey statement number 6
The reason why I enrolled in this online course is (“In the future, I would be willing to take an online course
because I’m extremely busy and I couldn’t always again.”), as shown in Table 3.
make it in person. [W8]
Table 3. Caregiver participant postcourse survey results (n=35).a
Item number Survey statement Agree, n (%) Somewhat agree, n (%) Disagree, n (%)
1 I would recommend this course to a friend. 34 (97) 1 (3) 0 (0)
2 I am comfortable sharing my ideas in written format online. 14 (40) 15 (43) 4 (11)
3 I am confident using and contributing to an online discussion group when 15 (43) 12 (34) 5 (14)
I need help or information.
4 I feel comfortable assessing the information I discover online for their in- 17 (49) 15 (43) 0 (0)
tegrity and truthfulness.
5 I am satisfied with the level of interaction in this course. 26 (74) 6 (17) 2 (6)
6 In the future, I would be willing to take an online course again. 30 (86) 4 (11) 1 (3)
a
Response rate was not 100% for all questions.
More specifically, several participants praised the flexibility of It was presented in a manner that would be palatable
the course and their ability to participate wherever and to older adults who are quite busy. [S5]
whenever. One respondent noted: Similarly, one member of the focus group of nursing students
The material ... lent itself well to doing things also agreed:
independent and online—which is what I was looking Having it on their own terms ... knowing they have it
for. [F11] right in their own home, was valuable to them. [NS5]
Quite a few caregivers spoke to the self-paced nature of the The flexibility of module information intake was highlighted
course, mentioning how the ability to “[do] it on my time” (W9) as another important feature:
and “hop online anytime that works” (W4) was extremely
valuable to them. One participant described how the flexibility I liked how you could stop and play at your own pace.
of the course benefitted their level of access: [W8]
Another caregiver stated:
I could participate in the course at home, when I’m
at school; it didn’t prevent getting access to the It was a good thing because you could go back if you
information in any way ... doing it online was the best forgot anything. [W12]
option. [F3] Other participants talked about repetition in viewing module
Although some liked the fact that “[i]t’s in the comfort of your content:
own house” (W7), others enjoyed the ability to log into the
I’ve gone through it a couple of times. [F5]
course from work “on and off throughout the day, and during
my lunch breaks” (W3). I could go back and look at some of the modules I
had already finished, just to kind of review. [W5]
As one respondent put it:
Others chose to only read through the information that was most
It was a good way because ... for all the caregivers, relevant to them:
we all have different times of when we’re available.
I kind of just scanned over ... really focused on the
[W10]
things that I needed. [F8]
This strength was realized and echoed by one stakeholder as
The control over choosing how much time to invest in the course
well:
and in each section of the modules seemed beneficial:
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You can spend as much time or as little time on those Therefore, it seems that both access to the web-based course
modules as you like. [W2] itself as well as ease of accessing information within the course
An additional element of accessibility was the free course were 2 highlights of the user experience.
registration. A number of caregivers expressed appreciation for The discussion boards were another well-accepted element of
the affordability of the course in their interviews (F3, F8, W3, web-based delivery, as reported by numerous participants. Many
and W11). Accessibility was considered throughout the whole believed that the opportunity to connect with other participants
design process, as stated by one project stakeholder: was an important part of the course:
A distinct strength was that this was a “no cost,” open There was a common camaraderie. It was nice ... that
opportunity for caregivers. We worked hard to ensure you do have that option to connect. [W4]
there would be as few hurdles to access as many
One caregiver described discussing shared experiences as “really
online materials as possible. [S4]
comforting in a lot of ways” (F12).
Besides reducing financial barriers, the web-based aspect of
Caregiving Essentials also helped to tackle geographical For the less experienced caregivers who did not contribute to
limitations: the discussion boards, some still found the posts to be “kind of
refreshing to get the perspective that there’s lots of people out
Technology ... can facilitate crossing a barrier, there dealing with this” (F11).
including the barrier of geography ... Again, it ties
into access. [S4] Newer caregivers were able to read posts from more experienced
caregivers and consequently felt more prepared:
As one stakeholder stated:
It’s more hearing what other people have to say and
It’s an online course and we very specifically reached
seeing what I have to look forward to ... or not look
out to people who were living in Northern Ontario.
forward to. [W5]
[S6]
The benefits of the discussion boards were also realized by
One interviewee spoke about the lack of accessibility of care
stakeholders and nursing students:
resources in the North from personal experience:
The idea that people could talk to each other, get to
...because of my northern roots and because I’m
know each other, share stories with each other. [S6]
working up in education in the north, I knew that
there’s a tremendous need for this kind of education. Another interviewee made the following observation about the
[S4] discussion board activity:
Web-based delivery ensured that even informal caregivers in People were using it to either commiserate or to
remote regions of the province had equal access to the course. justify some of the decisions they are making as
One participant specifically praised the project leadership for caregivers themselves. [S3]
targeting recruitment efforts to Northern communities in Likewise, they were described as “[r]eally important for the
Ontario: caregivers to feel that they were supported in their role, and
I thought that was excellent because you’re reaching kind of feeling that they weren’t alone” (NS3). Another focus
the people that are—there’s a whole bunch of need group member said they were “essential to the course in order
obviously ... They’re really isolated it feels. [F10] to relate with other caregivers” (NS2).
Another strength identified under accessibility was the Aligning with the caregivers’ feedback, one nursing student
user-friendliness of the course. One participant commented: described the sharing of experiences as creating “a sense of
camaraderie” (NS4), whereas another referred to it as a
I was very impressed about how the course was set
“community with peer support” (NS5).
up, how easy it was to access, and how easy it was to
maneuver through all the areas. [W1] In addition, one student noted:
Another remarked: The discussion board gets interaction going ...
The navigation through the learning or training was different caregivers answer back ... help each other
straight forward, well labeled, the links all worked, out. [NS1]
everything was functional and very easy to use. [W12] Even among the caregivers who did not use the discussion
The feedback from the nursing students involved in the course boards, some still saw value in incorporating social interaction
reflected participants’ comments: for others:
The course is very easy to navigate ... it was really I never get involved with that kind of thing, but I think
well organized. [NS4] that’s great ... You don’t want to feel like, “Am I the
only one going through this?” [W7]
One caregiver who initially experienced difficulties explained
that the navigation became easier over time: As mentioned in some of the caregiver interviews, part of the
reason for lower participation in the discussion boards was
It took me a bit the first module to find out how to get simply personal preference or prioritizing learning from the
to the next, but once I did that, it was okay. [W5] modules over making new connections with others.
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In terms of web-based delivery aspects that participants liked I had difficulty navigating out of the discussion board
and would keep the same, 8 participants mentioned the ... I would always end back at the home screen and
postmodule quizzes, and 8 participants mentioned the web-based then have to go back into the module. [F2]
support relating to course information, information technology Someone else mentioned:
troubleshooting, and general questions. Regarding the self-check
quizzes after each module, one nursing student expressed: I’m pretty savvy with computers so it wasn’t so much
that I didn’t know how to access it. I just found it a
I really liked that it tested your knowledge. [NS2] little bit clumsy with the windows and having to scroll
Another student commented: down. [F4]
I think that the modules are already quite interactive One of the older caregiver participants remarked:
when testing your knowledge. [NS4] I didn’t try because I couldn’t figure out how to make
During the focus group, the nursing students also described the it work. [F5]
value in caregivers having the option to reach out to them for Older participants and/or those living in Northern areas face
help with the course: their own barriers to accessibility, as noted by one participant:
I know the email was good too. They could directly It’s unfortunate being online, there’s so many people
contact us if they were having issues with IT, or if in the community who don’t have internet or don’t
they had ... more sensitive issues that they wanted to have access to internet ... in Northern Ontario. [F13]
discuss. [NS2]
One interviewee commented:
Thus, the more interactive elements of the course seemed to
enhance the participants’ overall experience. This qualitative I have a computer, [but] a lot of people do not in my
feedback corresponds with the postcourse survey results, as age bracket. [F4]
shown in Table 3. Most respondents agreed (26/35, 74%) or Even when participants had access to a computer and the
somewhat agreed (6/35, 17%) to survey statement number 5 (“I internet, a lack of comfort with using technology and web-based
am satisfied with the level of interaction in this course.”). platforms proved to be another barrier to participation:
Furthermore, the variety of resources used to deliver information I am 75 ... Not everybody this age is limited in their
was also identified as a positive factor: computer experience, but unfortunately, I am one of
them that is. [F5]
I hadn’t encountered such a comprehensive collection
of resources. Also, in terms of types of resources—so Comparably, another person declared:
videos, documents, templates. [F12] I’m 70, so I’m not as computer literate ... so things
Likewise, someone else highlighted this as a strength: are a little more difficult for me. [W5]
I liked the fact that there was a variety of different This limitation was also highlighted by one of the nursing
ways to get the information. You had the odd case students in the focus group:
study, you had a link to another website, ... Depending on how old the caregiver is, they may not
downloadable files. [W12] be “technology acceptable,” or able in a way. [NS5]
One stakeholder also referenced this strong point: One of the students even said that they found that “the site isn’t
The other thing that I think was really good about the most intuitive” (NS4), which could make accessibility more
this project was that it brought a whole lot of different of a challenge for certain participants, especially older ones.
resources together in one place. [S6] Another barrier to participation in the web-based course was
Barriers to Web-Based Delivery the lack of peer engagement experienced by some users. Certain
individuals felt the discussion boards were lacking interaction
Although many participants from all 3 groups cited accessibility between caregivers:
as a major strength of web-based delivery, there were some who
identified limitations with the navigation: There weren’t many people at all engaged in sharing
information, which is a shame because I think we’re
When I was going into a video or something, it would all on the same journey. [W9]
go into the video and then it was hard for me to go
back. [W10] Someone else expressed the desire for lengthier conversations:
A different participant described a similar situation: I would’ve liked to see a back and forth more with
what people were saying ... I would’ve liked to have
Certain links take you to other places and navigating had more discussion on what other people’s opinions
to get back to the original place ... was a little bit were. [W10]
challenging. [W4]
A caregiver described how a sense of community was not there
Another caregiver also shared about some trouble with for them:
web-based functionality:
One of the reasons I’d join the course was to perhaps
be part of the community, be part of the tribe, dealing
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with the same issues. I just didn’t find that. People Another recommended upgrade for web-based delivery was to
that perhaps did log in weren’t consistent in logging organize the content so that more information is presented
in. Or people that had very similar issues to what I broadly via modules and so that each module contains more
was going through, I couldn’t find them again on specific information through a series of different subsections
various chat boards. [W11] (F1, F14, and W11). This structure would streamline content
Another caregiver cited the self-paced nature of the course as better and make it easier for caregivers to find what they are
being problematic in this way as well: looking for. Some participants said that there was too much text
to read (F3, F5, W4, and W10), and it was suggested to either
I went through it faster than what was recommended add a feature that reads the text or include more video clips into
... so because of that, there was nothing in the online the modules (F3). Other proposed enhancements were to offer
chat because other people hadn’t gotten there yet. a download option for the material (W11) and to include short
[W5] testimonies from informal caregivers and/or older adults (W6).
One reason for the lack of discussion board participation was
The last theme that arose was the opportunity for future growth.
the concerns with sharing private information on the web:
A couple of caregiver participants recommended that the course
I wasn’t ready to share on the internet. [F5] should be opened to a broader and larger audience, such as other
Another respondent reiterated this worry: types of caregivers, caregivers living in other provinces, and
other care workers (F10, W1, and W4). The web-based delivery
I wasn’t comfortable using my personal experience of Caregiving Essentials would certainly enable scalability to
in an online public discussion. [W8] the national level because geographical barriers are reduced.
These comments were also reflected in the postcourse survey Course expansion was also brought up in several stakeholder
results, as shown in Table 3. Statement number 2 (“I am interviews:
comfortable sharing my ideas in written format online.”) and
In terms of how the course is actually designed, it
number 3 (“I am confident using and contributing to an online
certainly could handle a larger audience. [S6]
discussion group when I need help or information.”) had the
lowest participant agreement levels (14/35, 40% and 15/35, A total of 2 factors that would need to be addressed while
43%, respectively). scaling up the course would be ensuring that the information
and resources in the modules are kept updated (S3 and S6) and
Suggestions to Improve Web-Based Delivery remain region-specific (S2 and S6).
Recommendations for improving engagement between
participants included adding a discussion thread where Discussion
caregivers could share resources (F3), creating small
participation groups based on geographic location (W12), and Principal Findings
using a telecommunication for live discussions (F3, F4, F7, F11, Many of the strengths and areas of improvement identified by
W3, and W9). Some people specifically referred to integrating the caregiver participants aligned with the feedback from the
videoconferencing and emphasized the significance of project stakeholders and nursing students. The web-based
face-to-face interactions. However, as some participants had delivery of the Caregiving Essentials course enabled course
expressed security concerns, one caregiver’s idea could be used accessibility for most of the informal caregivers who participated
as a potential solution: in the study. Stakeholders were aware of informal caregivers’
busy and often unpredictable schedules, so the course was
My name was on the post. Is there a way to make it
designed to be flexible, which participants valued a great deal.
anonymous or change your identity when
The self-paced, independent nature of the course was made
commenting? My concern was anonymity for myself
possible by web-based, stand-alone modules. Participants liked
and for my family members. [W11]
the fact that they could access the course from home, work, or
Not using full names or even using pseudonyms or usernames school whenever they had free time. Some also found it helpful
could also be applied to a video call feature as a way to maintain that they could pick and choose which information they wanted
some aspect of privacy. to focus on and could even go back to the review material if
Some improvements for the discussion boards, as suggested by needed. This flexibility was highlighted as a benefit by the
the project stakeholders, were using caregivers as moderators stakeholders and nursing students.
to offer more of a “peer-to-peer experience” (S1) and creating The reported strengths from the project evaluation align with
smaller discussion groups to “connect [those] who were living the findings from the existing literature. In the evaluation of the
in the same areas” (S6). Connect, Assess, Respond, Evaluate, and Share (CARES)
Other ideas to enhance participant interaction were using Dementia Basics Program for caregivers by Pleasant et al [13],
additional communication methods, such as a web conference convenience, portability, and customizable learning speed are
(S1) or audio-video chats (S4). One interviewee remarked that cited as advantages of web-based learning programs. Moreover,
when “you can see someone’s face, and who they are, it makes accessibility was identified as one of the main benefits of the
a big difference” (S2). web-based modality for an individual psychoeducational stress
management training program offered on the web to family
caregivers [14]. In addition, the convenience and suitability of
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asynchrony and the ability to personalize use were noted as Essentials. The positive feedback for these course components
favorable features of internet-based social support networks by corresponds with the elements identified among other web-based
caregivers of older adults [15]. interventions that have been shown to be effective in previous
work. Boots et al [16] found that multicomponent internet
Only 1 participant thought that the web-based delivery
interventions that combined tailored information with
specifically hindered their course experience, which was due
interactions among caregivers were the most promising for
to their lack of experience with computers and technology.
improvements. Similarly, in the systematic review of
Others also shared some experiences of having difficulty
internet-based interventions for caregivers of older adults by
navigating through certain areas of the course. Although several
Guay et al [17], a combination of interactive web-based
participants described the course as easily accessible,
activities and the provision of human support are 2 components
user-friendly, and straightforward, a few referred to sections of
that have been shown to contribute to intervention efficacy.
the course as being clumsy or sporadic. This variation in
feedback may be caused by individual factors, such as A couple of participants mentioned that they liked the various
familiarity with web-based courses or generational differences ways in which information was presented, although numerous
in the use of technology. The disparity in positive and negative people suggested that even more multimedia types should be
responses can also be due to areas of the course that need to be added to the modules to help reduce the amount of onscreen
improved to better suit the diverse needs of various users. text. Increasing the level of engagement was another
recommendation made by the stakeholders, nursing students,
The discussion boards were another major strength identified
and participants. Specific improvements that were suggested
by the stakeholders, nursing students, and participants, as they
included adding web conference presentations, smaller group
made the course more engaging. The course designers created
chats, and live video calling. Telecommunication applications
discussion board topics that coincided with the module topics
such as Google Hangout and Skype were brought up, as many
to encourage participant activity. The main goal of web-based
people emphasized the importance of face-to-face connections.
communication was to increase interaction among users and to
This is consistent with the findings from the literature. In a
combat social isolation. Many participants reported a sense of
qualitative study by Ploeg [28] on a web-based transition toolkit,
community and camaraderie. The nursing students who
My Tools 4 Care, participants suggested that adding a feature
moderated the discussion boards confirmed the positive
to enable caregivers to connect with one another (in real time
connection that was building when they spoke about participants
or asynchronously) to share information, experiences, and
sharing stories and giving each other advice.
caregiving strategies would be helpful. Furthermore, in
Connecting with other caregivers was also a strength observed comparing 2 internet-based intervention programs, Marziali
in other studies. In a systematic review of web-based and Garcia [10] found that the videoconferencing intervention
interventions for caregivers by Parra-Vidales et al [18], they program was deemed more useful in improving caregivers’
found that allowing participants to have a direct web-based mental health status than the chat-based intervention. This is
contact with other caregivers contributed to the effectiveness useful considering that the discussion boards within Caregiver
of the interventions. In the study by Barbabella et al [20] on a Essentials were intended to reduce social isolation.
web-based psychosocial intervention for family caregivers of
Another important theme was geography and the role it played
older people, findings revealed positive effects on social
throughout the project from the recruitment process to the data
inclusion and support from the interactive services that enabled
collection stage. Some of the participants were specifically
communication among participants. In the study by Godwin et
recruited from Sudbury and Timmins in Northern Ontario, where
al [21], all studies involving technology-driven interventions
there is a lack of resources and accessibility barriers for the ones
for caregivers that were reviewed had some positive findings,
that do exist. Therefore, the participants’ ability to access the
and each had an information and social support component.
course and their insights from the interviews about web-based
Not all participants found the discussion boards to be beneficial. delivery were especially appreciated because they represent an
The postcourse survey results provided in Table 3 show that underserved subgroup among informal caregivers. Stakeholders
around half of the respondents were not confident in sharing belonging to the project leadership team were knowledgeable
their ideas in a written format on the web. This correlated with about service access limitations in Northern Ontario. Therefore,
the participants who had privacy concerns and did not wish to the web-based delivery of the course reduced spatial barriers
share personal information on the web. Some participants found and allowed for equal participation from caregivers, regardless
the discussion boards to be challenging to navigate, others of where they were located. The accessibility of the intervention
prioritized exploring the module content, and a few accessed to remote regions was also emphasized by Marziali and Donahue
the discussion boards when there was little interaction. These [22] in the pilot feasibility study on Caring for Others, an
experiences have been found elsewhere among caregivers of internet group intervention for family caregivers of older adults.
older adults. In the study by Colvin et al [15] on exploring
This is a key factor to recognize, especially if the project were
computer-mediated communication, the complaints that arose
to expand to other geographic areas. Using some of the domains
included concerns around anonymity, a lack of adequate
of the nonadoption, abandonment, scale-up, spread, and
response, and a lack of privacy or confidentiality.
sustainability framework, there are some characteristics of
Other interactive features, such as the postmodule quizzes, the Caregiving Essentials that show promising results in terms of
downloadable Caregiver Action Plan, and email support, were evaluating the potential for future effectiveness and success
also said to enhance the overall experience of taking Caregiving [29]. For the technology domain, the intervention lies
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somewhere between the simple and complicated categorization then there may not have been such a loss in numbers between
because some participants did not need a set of instructions to the pre- and postcourse surveys.
access and navigate the course, whereas others did make use of
the detailed instruction and helpdesk support. For the value
Conclusions
proposition domain, the technology is desirable for its intended In conclusion, this evaluation of web-based delivery of the
users, safe, and cost-effective; therefore, it would lean more Caregiving Essential course demonstrated acceptability and
toward being labeled a simple innovation. For the last domain usability for many of the participants. A diverse range of
of the framework, there is a strong scope for adapting and accessibility topics and the ways in which they enabled
embedding the technology as local need or context changes. participation in the course were discussed in the stakeholder
and participant interviews and the student focus group.
Limitations Suggestions to further develop the existing interactive features
A limitation of the evaluation was the recruitment strategies of the intervention were made, as well as recommendations to
used to recruit participants. Only caregivers who had finished incorporate additional methods of engagement via technological
most of the module content were contacted for an interview. opportunities were provided. Although there were some barriers
Therefore, if participants stopped partway through, they were to participation due to web-based delivery, most respondents
never given the opportunity to provide in-depth feedback were able to overcome them and still benefit from the course.
pertaining to the web-based delivery of the course. The topic Web-based delivery of the knowledge intervention had many
of evaluation is one in which participants would likely still be advantages and positively impacted informal caregivers’
able to provide feedback on if they had completed at least one experiences in taking the course. The proposed areas of
module and had explored other features of the course. Thus, it improvement offered feasible changes, and several changes
is possible that participants who qualified to be involved in the were implemented for future course offerings following the
evaluation (ie, finishing most of the module content) were more evaluation.
likely to offer certain types of responses. This means that the
Further use or investigation is warranted to evaluate the
participant interview data may not accurately represent the
effectiveness of web-based delivery for this course and other
perspectives of everyone who took the course.
existing and emerging web-based interventions for informal
Furthermore, the voluntary aspect of the project’s evaluation is caregivers of older adults. This population experiences a great
another potential factor that may reduce the generalizability of need for credible, relevant, and up-to-date information and
the participant interview findings. Again, individuals who agreed resources. It is key that the web-based modalities of
to provide feedback may be more likely to hold extreme interventions for caregivers enhance accessibility and enable
opinions, whether positive or negative. Moreover, as the meaningful human interactions. The findings from this
evaluation was not mandatory, the number of participants who evaluation can support the creation and improvement of the
completed each step decreased throughout the duration of the current and new interventions. It can also be applied to
project. If participation in the Caregiving Essentials course was innovations related to other populations that provide care to
tied to participants’ commitment to provide evaluative feedback, older adults.
Acknowledgments
The authors would like to thank McMaster University and the School of Earth, Environment, and Society. The authors would
also like to thank the members of the McMaster Centre for Continuing Education, the McMaster Institute for Research on Aging,
and the Thrive Group for creating and running the Caregiving Essentials course. The authors would like to thank their close
family and friends for their love and support. The authors would also like to thank all the participants involved in the evaluation.
This research was funded by the Canadian Institutes of Health Research Chair Program in Gender, Work, and Health (CG1
1265885 grant) and a Ministry of Seniors Affairs Grant (2018). The continuation of this course was made possible through a
partnership with the Regional Geriatric Program of Ontario.
Conflicts of Interest
None declared.
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